Basic Information
| Provider Information | |||||||||
| NPI: | 1487844973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 E 91ST ST | ||||||||
| Address2: | APT 1805 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101285354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122136402 | ||||||||
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| Practice Location | |||||||||
| Address1: | 89-06 135TH ST | ||||||||
| Address2: | ROOM 6A | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182066808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 60 245188 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.